Tsvieli O, Atoun E, Consigliere P, Polyzois I, Walecka J, Pradhan R, Ippolito G,. Rath E, Levy O (2018) Manipulation under anaesthetic for frozen shoulder using.
Comments on article by Tsvieli et al.: manipulation under anaesthetic for frozen shoulder using Codman’s paradox: a safe and early return of function Dear Editor, We read with great interest the recent article by Tsvieli et al.[1]. The authors proposed a manipulation technique under anesthesia for treating frozen shoulder on the basis of Codman’s paradox. The aim of developing this technique was to avoid the rotational torque on the humerus, thereby decreasing the risk of iatrogenic fractures during the manipulation. With significant improvement in range of motion and pain and without any complications, the authors concluded that their technique is not only safe but also efficient in treatment. We appreciate the authors’ great work on developing this technique, and we have some comments about this study. 1. The stage of frozen shoulder was not clearly illustrated. Frozen shoulder could be divided into 3 stages: (1) the freezing stage, lasting 2.5 to 9 months; (2) the frozen stage, lasting 4 to 20 months; and (3) the thawing stage, lasting 5 to 26 months [2,3]. The treatment effects in different stages would possibly be different. The authors have reported a mean duration of 8.81 ± 5.47 months from symptoms leading to manipulation; however, the clinical stages of these patients were not described in detail [1]. This information is important because readers might be interested in the optimal timing for conducting this technique for the patient. 2. Not only the manipulation but also the intra-articular steroid injection was performed. Tsvieli et al. reported that 10 ml of 0.25% bupivacaine and 40 mg of methylprednisolone acetate were injected into the glenohumeral joint after manipulation [1]. According to a recent meta-analysis [3], intra-articular steroid injection has positive effects on pain relief, improving functional performance, and increasing range of motion for these patients for as long as 24 to 26 weeks. Although Tsvieli et al. reported that their patients received the manipulation after failure of non-surgical treatment modalities, it was not clear whether all of these patients received steroid injection before [1]. Consequently, both steroid injection and manipulation would contribute to the treatments effects on these patients. To better understand the effect of this manipulation technique on treating frozen shoulder, comparative studies with control groups are required in the future. Despite these concerns, the authors proposed an attractive technique and made a great contribution to this topic.
Reference: 1. Tsvieli O, Atoun E, Consigliere P, Polyzois I, Walecka J, Pradhan R, Ippolito G, Rath E, Levy O (2018) Manipulation under anaesthetic for frozen shoulder using Codman's paradox: a safe and early return of function. International orthopaedics 42 (2):339-344. doi:10.1007/s00264-017-3558-3 2. Lewis J (2015) Frozen shoulder contracture syndrome - Aetiology, diagnosis and management. Manual therapy 20 (1):2-9. doi:10.1016/j.math.2014.07.006 3. Sun Y, Zhang P, Liu S, Li H, Jiang J, Chen S, Chen J (2017) Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis. The American journal of sports medicine 45 (9):2171-2179. doi:10.1177/0363546516669944
